A Pilot Study of Femoropopliteal Artery Revascularisation with a Low Dose Paclitaxel Coated Balloon: Is Predilatation Necessary?

OBJECTIVE/BACKGROUND: The objective was to compare 2 year outcomes in patients treated with or without predilatation prior to drug coated balloon (DCB) angioplasty for symptomatic femoropopliteal lesions. METHODS: This prospective multicentre pilot study was conducted at three sites in Germany. It compared claudicants undergoing predilatation with a bare percutaneous transluminal angioplasty (PTA) balloon before DCB (predilatation group) with patients undergoing direct DCB (direct DCB group). Patients were followed for 2 years. Outcomes included late lumen loss at 6 months, and ankle brachial index (ABI), major adverse events, and primary patency at 2 years. A Clinical Events Committee and core laboratories analysed adverse events and angiographic/duplex images, respectively. RESULTS: Between December 2011 and November 2012, 50 patients were enrolled to the predilatation group (12% total occlusions) and 28 to the direct DCB group (5% total occlusions). Follow-up compliance at the 2 year visit was 88% (n = 44) and 86% (n = 24), respectively. Late lumen loss at 6 months was lower in the direct DCB group (0.03 ± 0.68 mm vs. 0.54 ± 0.97 mm; p = .01). Major adverse events over 2 years occurred in seven (15%) patients who underwent predilatation and in five (19%) after direct DCB. Mean ABI at 2 years was 0.94 ± 0.15 after predilatation and 1.0 ± 0.12 after direct DCB. Over 2 years, primary patency (80.3% vs. 78.2%; p = .55) was not statistically different between the groups. After propensity score adjustments, 2 year findings remained unchanged. CONCLUSION: Paclitaxel coated PTA, with or without bare predilatation, is effective over 2 years in symptomatic patients with femoropopliteal stenotic lesions. Adequately powered randomised controlled comparisons are required to confirm these preliminary results.

Bis-basic-substituted polycyclic aromatic compounds. A new class of antiviral agents. 7. Bisalkamine esters of 9-oxoxanthene-2,7-dicarboxylic acid, 3,6-bis-basic ethers of xanthen-9-one, and 2,7-bis(aminoacyl)xanthen-9-ones-xanthenes, and -thioxanthenes.

3,6-Bis[2-(dimethylamino)ethoxy]-9H-xanthen-9-one dihydrochloride (4, RMI 10874DA) and 1,1'-(9H-xanthene 2,7-diyl)bis[2-(dimethylamino)ethanone] dihydrochloride (16, RMI 11513DA) were found to prolong survival of mice infected with lethal challenges of encephalomyocarditis (EMC) virus. They were effective by oral as well as subcutaneous administration and showed broad-spectrum antiviral activity. They were selected for preclinical evaluation from the five series of compounds named in the title that were synthesized in analogy to tilorone and related fluorenone derivatives, described earlier. In addition to 4 and 16, compounds 11, 12, 17, and 18 showed high antiviral activity on oral as well as subcutaneous administration. High antiviral activity on subcutaneous admistration was found in the bisalkamine esters 1,2, and 14, the bis(aminoacyl)xanthenes 23 and 26, the bis(aminoalkylene)xanthene 31, the bis(aminoacyl)thioxanthenes 34-40, and the bis-basic ethers of 9-benzylide-nexanthenes 41 and 42. Structure-activity relationships showed a decrease of oral activity with increased length of side chains and increased molecular weight of dialkylamino substituents of 3,6-bis-basic ethers of xanthen-9-one and of 2,7-bis(aminoacyl)xanthenes and-xanthen-9-ones. At least one carbonyl or alkenyl function in conjugation to the xanthene nucleus either at the 9 position of the nucleus or in the side chains is required for high antiviral activity.

The role of tetracycline in chronic blepharitis. Inhibition of lipase production in staphylococci.

Tetracycline administered in low doses can be effective in the long-term management of patients with meibomian keratoconjunctivitis (MKC). However, the mechanism of action does not appear to be a reduction of bacteria. Seventy-five percent of the ocular staphylococci in such patients are resistant to tetracycline. An alternative mechanism of action could be the inhibition of production of extracellular enzymes by the ocular flora. Inhibition of lipase production could result in lowered levels of toxic hydrolysis products (free fatty acids), which may exacerbate the disease process. The authors tested this hypothesis by examining the differential effect of tetracycline on growth and lipase production in a tetracycline-resistant and tetracycline-sensitive strain of Staphylococcus epidermidis and S. aureus isolated from patients with MKC and Staphylococcal blepharitis. Tetracycline caused significant decreases in the production of lipase in the sensitive and resistant strains of S. epidermidis without concominant decreases in growth. In contrast, S. aureus strains showed parallel decreases in both lipase production and inhibition of growth. The authors propose that the sensitivity of lipase production to tetracycline, in tetracycline-resistant S. epidermidis, may partially explain the clinical improvement observed in MKC patients.

In vivo and in vitro collagenolytic activity of Acanthamoeba castellanii.

Axenic cultures of Acanthamoeba castellanii contained a collagenolytic enzyme that digested collagen shields and purified collagen in vitro. Specificity of biologic activity was determined by the addition of selected enzyme inhibitors to the assays and revealed that the parasite-conditioned medium contained both collagenase and lower concentrations of other proteolytic enzymes. However, most of the collagenolytic and pathogenic activity was directly attributable to specific collagenase. Intrastromal injection of sterile, Acanthamoeba-conditioned culture medium into naive Lewis rats produced corneal lesions clinically similar to and closely resembling those found in biopsy specimens of human patients diagnosed with acanthamoebic keratitis. Histopathologic analysis revealed moderate-to-severe neutrophil infiltration, disruption of stromal lamellae, and edema. Identical pathologic sequelae were produced by intrastromal injection of purified collagenase (25 units/ml). The pathogenicity of the soluble parasite-derived product was removed by passage over affinity columns armed with antibody specific for collagenase. These results indicated that soluble parasite-derived factors were capable of producing lesions characteristic of acanthamoebic keratitis and that the pathogenicity of these factors was either directly or indirectly attributable to specific collagenase activity.

Susceptibility of corneas from various animal species to in vitro binding and invasion by Acanthamoeba castellanii [corrected].

A crucial requirement for establishing corneal infection by the extracellular protozoal parasite, Acanthamoeba, is the ability of the parasite to bind to the corneal surface. In a series of in vitro studies, we examined the ability of Acanthamoeba castellanii [corrected] to adhere, invade, and damage normal, intact corneas of 11 mammalian and one avian species. A. castellanii [corrected] (80-90% trophozoites and 10-20% cysts) were incubated with corneas for 24 hours in vitro and examined by scanning electron microscopy (SEM). Results of several independent SEM experiments revealed that parasites not only failed to produce cytopathic effects but did not even bind to the corneal epithelium of mice, rats, cotton rats, horses, guinea pigs, cows, chickens, dogs, and rabbits. However, parasites adhered, invaded, and produced severe damage to human, pig, and Chinese hamster corneas during the 24-hour in vitro incubation period. Additional in vitro experiments quantified the binding of A. castellanii [corrected] to the corneas of selected susceptible and nonsusceptible species. In vitro binding assays revealed scant binding of parasites to mouse, rat, and rabbit (range = 5-20 parasites/7.07 mm2 corneal button). In contrast, extensive binding was observed on Chinese hamster, pig, and human corneas (range = 100-200 parasites/7.07 mm2 button). The results indicate that A. castellanii [corrected] exercises rigid host specificity at the host cell surface.

Pronounced cystic transformation of the Rete testis. MRI appearance.

BACKGROUND: Cystic transformation of the rete testis is a little-known partial or complete obstruction of the spermatozoa-containing secretion of the head of the epididymis. Depending on its severity, either ectasia or a cystic transformation occurs, which spreads to the network of convoluted seminiferous tubules in the mediastinum testis. Findings in contrast-enhanced MRI examinations are characteristic and may help to differentiate this benign entity from malignant neoplasia. The authors present two pronounced cases in different stages, documenting the broad spectrum of possible involvement.

Intra- and infrahepatic agenesis of the inferior vena cava with azygos continuation accompanied by duplication of the postrenal segment.

Agenesis of one or more segments and duplication of the infrarenal segment are, individually, rare abdominal variants of the inferior vena cava (IVC). In this article, the authors report on a case in which these two anomalies occurred concurrently. Details of the embryology are presented insofar as they are necessary for an understanding of this IVC variant. Spiral computed tomography makes it possible to define the vascular morphology and to make a differentiation from lymphadenopathy. Cavography gives an overall picture of the vascular morphology.

Early office-based vs late hospital-based nasolacrimal duct probing. A clinical decision analysis.

BACKGROUND: Controversy exists regarding the treatment of infants with symptomatic nasolacrimal duct obstruction. One philosophy advocates "early" nasolacrimal duct probing, generally in the office. An alternate strategy advocates medical management until the infant is approximately 12 months old to allow for spontaneous resolution, with those with persistent nasolacrimal duct obstruction usually treated by "late" probing in the hospital with the use of general anesthesia. METHODS: We used clinical decision analysis to compare these two opposing treatment strategies. A decision tree was constructed with the usual designations for probability nodes and decision points, comparing early probing at 6 months of age in the office and late probing at 12 months of age in the hospital. The initial decision point thus addressed treatment of children who still had symptomatic nasolacrimal duct obstruction at 6 months of age. One repeated probing under same-strategy conditions was performed for patients in whom initial office probing failed. Values for probability nodes were derived from the ophthalmic literature, including a 70% rate of spontaneous resolution of nasolacrimal duct obstruction between the ages of 6 and 12 months. RESULTS: Both the early office probing strategy and the late hospital probing strategy yielded success rates greater than 99%. Based on prevailing fees, the late hospital strategy cost $2,310,000 more than the early office strategy per 10,000 patients, even though fewer procedures were performed. CONCLUSION: Early office probing and late hospital probing have similar high success rates, albeit at a higher cost for the late hospital probing strategy.

Management of canalicular injury associated with eyelid burns.

PURPOSE: To develop a protocol for treatment of injuries to the puncta and canaliculi associated with eyelid burns. METHODS: We retrospectively reviewed the records of seven patients who required treatment of punctal and canalicular stenosis caused by burns to the medial eyelids. RESULTS: Seven patients were treated within 5 days of injury: one by punctal dilation and six by surgical debridement, punctoplasty or canaliculoplasty, and silicone intubation. All remained free of epiphora. CONCLUSIONS: Early evaluation and treatment of punctal and canalicular burn injuries are beneficial. If the puncta are only slightly stenotic, close observation with serial lacrimal testing and punctal dilation is recommended. If the puncta and lateral canaliculi are severely stenotic or obliterated, surgical débridement and punctoplasty or canaliculoplasty followed by placement of a silicone stent effectively prevents permanent lacrimal stenosis and epiphora.

Bilateral enophthalmos associated with hydrocephalus and ventriculoperitoneal shunting.

BACKGROUND: Progressive bilateral enophthalmos in the absence of previous trauma is rare. METHODS: Three patients with progressive bilateral severe enophthalmos whose only significant medical history was that of congenital hydrocephalus were treated by ventriculoperitoneal shunt placement. RESULTS: The patients demonstrated severe bilateral enophthalmos with poor eyelid apposition to the globes resulting in superficial keratopathy. Orbital computed tomographic scans confirmed the severe enophthalmos, with apparent reduced orbital fat volume. Orbital bony anatomy appeared normal. CONCLUSIONS: Bilateral progressive enophthalmos may be associated with hydrocephalus and ventriculoperitoneal shunting. The causal mechanism remains speculative.

Quantitating the superior visual field loss associated with ptosis.

The effect of blepharoptosis on the superior visual field was assessed using a series of specially designed contact lenses to simulate ptosis in normal subjects. We found a progressive decrease in the superior visual field at the 90 degree vertical meridian, which was proportional to the degree of simulated ptosis. Our results were in close agreement with both a theoretical model and previous clinical observations. These results are important in evaluating patients contemplating ptosis surgery, as well as in visual field testing for neuro-ophthalmic disorders.

Temporal neocortical injuries in rats impair attending but not complex visual processing.

The effects of variations of the distance between the relevant stimuli and the animals' response sites were observed upon the performances of a black-white discrimination habit for normal rats or subjects prepared with either bilateral injuries to the visual or temporal neocortex. In addition, the animals were given a strict test of visual form perception. Subjects with injuries to the visual cortex failed the test of visual form perception but performed like normals in discriminating a spatially discontiguous problem. In contrast, subjects with temporal injuries exhibited enormous performance deficits when trained on a spatially discontiguous problem but performed like normals on the test of form perception. The findings parallel the results of studies using primates and suggest that bitemporal injuries result in impairments of attending and not of complex visual processing.

Health insurance and child support.

This DataWatch examines the extent of the child support system's increasing efforts to require nonresident parents to provide health insurance for their children. More than half of children who have public insurance only and more than one-fourth of uninsured children live in families that could be affected by the child support system. Nonresident fathers now provide insurance to only 15 percent of children living with their mother. More than one-third of such children have public insurance only. Thus, if the child support system could ensure children's coverage through nonresident fathers, taxpayer spending on public insurance could decrease.

Effects of successive unilateral ablations of principalis cortex upon performances of delayed alternation and delayed response by monkeys.

Monkeys were trained on delayed alternation (DA), and were then subjected to serial unilateral or simultaneous bilateral ablations of the banks of the sulcus principalis of each frontal lobe. When subjects with unilateral lesions were retrained on DA, their performances were intermediate to those of normal and bilateral animals. This interoperative training failed to protect the serially operated monkeys from losses of DA following their second-stage ablations, for they then performed as poorly as one-stage subjects and subjects prepared with serial ablations that were not given practice on the task between the two operations. Additional postoperative tests of delayed responding (DR) showed that both serially and simultaneously ablated subjects also had severe impairments of performance of DR. This result confirmed, in principle, a finding that monkeys with large unilateral ablations, if reoperated after many months for the removal of the contralateral dorsolateral perfrontal cortex, will thereafter exhibit DR deficits that are both severe and endure for a period of years. It contrasted sharply with a recent observation that DR is retained by monkeys subjected to two-stage symmetrical ablations of the principalis cortex, which suggests that recoveries of frontal-lobe functions are powerfully affected by the orders in which serial extirpations are performed.

Silicone intubation without intranasal fixation for treatment of congenital nasolacrimal duct obstruction.

PURPOSE: We assessed the efficacy and morbidity of silicone intubation without intranasal fixation to treat congenital nasolacrimal duct obstruction. METHODS: Forty eyes of 30 consecutive patients underwent silicone intubation to treat congenital nasolacrimal duct obstruction. The ends of the silicone tubing were tied together with a single square knot and were allowed to retract into the nose without intranasal fixation. Tubing removal was performed in the office via the medial canthus in all patients. No attempt was made to reposition prematurely dislodged tubing. RESULTS: The success rate for this series was 38 (95%) of 40 eyes in 29 (97%) of 30 patients. Of seven eyes that required unplanned early tubing removal for dislocated tubing, five eyes nevertheless showed complete resolution of nasolacrimal duct obstruction. Only one patient underwent a second silicone intubation under general anesthesia. CONCLUSIONS: Silicone intubation without the use of intranasal fixation is an effective strategy for treating congenital nasolacrimal duct obstruction. It spares most patients from a second procedure under general anesthesia and achieves success rates comparable to previous studies in which more complex techniques were used.

Acquired lower eyelid epiblepharon.

PURPOSE: Although congenital epiblepharon is a relatively common condition, particularly in Asians, acquired lower eyelid epiblepharon is rare. METHOD: We examined an 8-year-old boy who developed unilateral lower eyelid epiblepharon after a subciliary incisional approach for repair of a zygomatico-orbital fracture. RESULTS: The patient demonstrated an overriding fold of right lower eyelid skin and loss of the lower eyelid crease. At the time of surgical repair, disruption and scarring of the lower eyelid retractors, suborbicularis fascia, and orbital septum were noted. The epiblepharon was successfully corrected by plication of the retractors and skin to the tarsus. CONCLUSION: Disruption of the anterior subcutaneous fibers of the lower eyelid retractors (that is, capsulopalpebral fascia) contributes to epiblepharon.

Juvenile xanthogranuloma of the lacrimal sac fossa.

PURPOSE: Masses involving the medial canthus and lacrimal sac fossa include dacryocystoceles and, less commonly, mucoceles, hemangiomas, diverticula, and lacrimal sac neoplasms. To our knowledge, juvenile xanthogranuloma presenting as a lacrimal sac fossa mass has not been previously reported. METHODS: We examined a 2-year-old boy who had epiphora in the left eye since birth and a mass in the left lacrimal sac fossa for 6 weeks. During surgery, left lacrimal probing disclosed obstruction at the level of the common canaliculus and lacrimal sac. Exploration and excision of the mass were performed. RESULTS: Histopathologic evaluation disclosed a juvenile xanthogranuloma characterized by an inflammatory cell infiltrate with foamy histiocytes and scattered Touton-type multinucleated giant cells. CONCLUSION: Juvenile xanthogranuloma should be included in the differential diagnosis of a medial canthal and lacrimal sac fossa mass.

Primary infratarsal lower eyelid retractor lysis to prevent eyelid retraction after inferior rectus muscle recession.

PURPOSE: To evaluate a procedure to prevent lower eyelid retraction, which may occur after inferior rectus muscle recession surgery as a direct consequence of the intimate anatomic connections between the inferior rectus muscle and lower eyelid retractors. METHODS: We evaluated the technique of primary infratarsal lower eyelid retractor lysis on 12 eyelids of ten patients undergoing inferior rectus muscle recession of 3 mm or more. Indications for surgery included restrictive strabismus related to Graves' ophthalmopathy, orbital blowout fracture, and orbital fibrosis syndrome. RESULTS: For the 12 eyes, inferior rectus muscle recession ranged from 3 to 10 mm (mean, 5.3 mm). Postoperatively there was no significant change in mean lower eyelid position (P > .82), and no patient developed inferior scleral show. CONCLUSION: Primary infratarsal eyelid retractor lysis is an effective technique for preventing lower eyelid retraction after inferior rectus muscle recession strabismus surgery.

Improvement in subjective visual function and quality of life outcome measures after blepharoptosis surgery.

PURPOSE: To examine patients' subjective perception of visual function and health-related quality of life as affected by blepharoptosis and the change in these perceptions after blepharoptosis surgery. METHODS: A 27-item questionnaire pertaining to vision-related activities and symptoms was used preoperatively to assess 50 consecutive patients (18 years old or older) with unilateral or bilateral acquired involutional blepharoptosis, and postoperatively six to eight weeks after blepharoptosis repair. RESULTS: Of the 24 items statistically analyzed, 16 items (67%) demonstrated significant improvement postoperatively (P < .05) among the unilateral cases and 18 items (75%) showed significant improvement postoperatively (P < .05) among the bilateral cases. The four activities that improved the most after surgery for both the unilateral and bilateral groups were the ability to perform fine manual work, hanging or reaching objects above eye level, watching television, and reading. CONCLUSIONS: Surgical repair of acquired involutional blepharoptosis resulted in significant improvement in several aspects of patients' subjective visual function and health-related quality of life. These issues are important in determining both the indications for and outcome of blepharoptosis surgery.

Increased intraocular pressure in the immediate postoperative period after extracapsular cataract extraction.

We evaluated the immediate intraocular pressure increase after extracapsular cataract surgery in 58 eyes. Two to three hours postoperatively, 34 eyes (59%) developed an intraocular pressure greater than or equal to 25 mm Hg. We found an intraocular pressure of at least 40 mm Hg in seven eyes. Mean intraocular pressure two to three hours postoperatively was 8.9 +/- 9.8 mm Hg greater than the preoperative intraocular pressure. The use of intraocular sodium hyaluronate had no apparent effect on intraocular pressure.